临床答疑

四川峨眉读者宋绍英问:(一)诊断性刮宫的适应证和禁忌证有哪些?答:诊断性刮宫为妇科最常用的诊断方法之一,主要目的为刮取子宫内膜作病理切片,以明确诊断指导治疗。分为一般性诊刮与分段诊刮两种。一般性诊刮的适应证。①不正常阴道流血:如疑有功能失调性子宫出血;子宫内膜息肉;不全流产;子宫内膜炎等。②不孕症需了解有无排卵。③疑有子宫内膜结核者。分段性诊刮是将宫颈管及宫腔刮出物,分别装瓶送病理切片,借此可诊断宫腔及宫颈的病变以及其病变     

放、取宫内节育器与人工流产手术及术后的感染问题

放、取宫内节育器与人工流产手术均系宫腔内操作 ,容易导致子宫内膜的创伤而发生感染。其感染途径一是由自身的细菌由外至内生殖器的上行性感染 ,另一个途径是由于手术没有按照严格的无菌操作规程操作 ,由术者及器械带菌入宫腔而产生的感染。放置宫内节育器 (IUD)要穿过宫颈管这一非无菌环境 ,特别是当穿过有宫颈管炎、慢性宫颈炎 ,例如已有支原体、衣原体、巨细胞病毒及淋球菌感染的患者的宫颈时 ,IUD的表面将微生物带入宫腔 ,引起宫腔暂时性炎性反应 ,宫腔可被少量带菌的宫颈粘膜感染 ,产生急性轻度子宫内膜炎 [1 ] 。炎症的程度依进入…     

细胞周期调控相关蛋白P53、P16、P21、Rb在子宫内膜癌的表达与意义

目的 :研究与细胞周期G1→S调控点相关的P5 3、P16、P2 1、Rb蛋白在子宫内膜癌的表达及其相关情况 ,探讨其临床应用价值。方法 :采用免疫组化 (LSAB法 )检测上述指标在 2 1例正常子宫内膜、15例子宫内膜上皮内瘤样病变 (EIN)及 4 5例子宫内膜癌中的表达。结果 :P5 3蛋白表达由正常内膜、EIN至内膜癌逐渐升高 ,而P16、P2 1、Rb蛋白结果相反 ;在子宫内膜癌中 ,P5 2和P2 1呈负相关 (r =- 0 .32 2 ) ,P16、P2 1与Rb呈正相关 (r=0 .36 1;r =0 .4 41)。P2 1蛋白表达与良好病理学分级有关 (P <0 .0 5 ) ,P5 3蛋白表达与临床各参数有关 ,与ER、PR的表达呈负相关 ,单因素及多因素分析均提示P5 3蛋白表达阳性的子宫内膜癌患者预后差 (P <0 .0 5 )。结论 :与细胞周期G1→S调控相关的P5 3、P16、P2 1、Rb蛋白均参与子宫内膜癌发生、发展 ,且部分基因相互关联 ,P5 3可作为独立预后因素应用于临床 ,其阳性表达提示预后不良     

子宫内膜损伤宫腔粘连评价指标的临床应用北大核心CSCD

各种原因引起的子宫内膜基底层损伤可导致子宫内膜纤维化及宫腔形态学破坏。临床上最常见的子宫内膜损伤代表性疾病是宫腔粘连。子宫内膜损伤宫腔粘连的主要临床表现为月经量减少、闭经、不孕;临床评价指标包括影像学、宫腔镜形态学及子宫内膜容受性指标。中华医学会妇产科学分会妇科内镜学组制定的宫腔粘连评分分级标准纳入了更全面有效的评价指标,对于子宫内膜损伤的精准评估、诊断及生殖预后结局的有效预测具有更高的临床应用价值。     

子宫内膜腺鳞癌临床病理特征及其预后研究

目的 探讨子宫内膜腺鳞癌患者的临床病理特征及预后。方法 选取1992年3月至2004年12月北京大学人民医院就诊的子宫内膜癌患者,分为普通子宫内膜样腺癌组、腺鳞癌组以及浆液性乳头状腺癌和透明细胞癌组进行回顾性研究。结果 腺鳞癌患者9例,占同期210例内膜癌患者的4.3%。普通子宫内膜样腺癌组与腺鳞癌组肿瘤分期差异无显著性意义（P〉0.05）;浆液性乳头状腺癌和透明细胞癌患者肿瘤分期明显晚于子宫内膜样腺癌患者（P〈0.05）。腺鳞癌组深肌层及浆膜层浸润较普通子宫内膜样腺癌组多,分别为6/9和32.6%（62/190）,但差异无显著性意义（P〉0.05）。腺鳞癌组与普通子宫内膜样腺癌组患者肿瘤细胞分化程度差异无显著性意义（P〉0.05）。18例（9.5%）普通子宫内膜样腺癌患者、1例（1/9）腺鳞癌患者以及4例（4/11）浆液性乳头状腺癌和透明细胞癌患者因癌死亡,子宫内膜样腺癌患者因癌死亡比例明显低于浆液性乳头状腺癌和透明细胞癌患者（P〈0.05）,而普通子宫内膜样腺癌组与腺鳞癌组差异无显著性意义（P〉0.05）。生存分析显示接受手术治疗的腺鳞癌患者,其预后与肿瘤分期相关（P〈0.05）。结论 子宫内膜腺鳞癌临床病理特征及预后与普通子宫内膜样腺癌无明显区别,而与浆液性乳头状腺癌和透明细胞癌不同。     

子宫颈黏液腺癌88例临床病理分析

目的 探讨宫颈黏液腺癌的临床病理特点,为其诊断、治疗及预后判断提供参考.方法 回顾性分析江西省妇幼保健院2003年1月至2007年12月收治的88例宫颈黏液腺癌患者的临床病理资料.结果 88例患者中,宫颈管型70例、微小偏离型11例、肠型2例、绒毛管状腺癌5例;Ⅰ期38例(Ⅰb1期24例、Ⅰ b2期14例),Ⅱ期32例(Ⅱa期10例、Ⅱb期22例),Ⅲ期18例(Ⅲa期1例、Ⅲb期17例).宫颈细胞学检查的阳性率仅为28％ (10/36).10例经反复细胞学检查及宫颈多点活检均未见明显异常的患者,其中7例经宫颈组织大块切除活检及宫颈管搔刮术确诊:5例为宫颈管型,2例为微小偏离型;2例经诊断性锥切确诊:1例为Ⅰ b1期宫颈管型腺癌,1例为Ⅰ b1期微小偏离型腺癌;1例Ⅰ b1期宫颈微小偏离型腺癌患者经宫腔镜下大块组织切除活检确诊.88例患者的总体5年生存率为60.0％,单因素分析显示,患者年龄、临床分期、肿瘤大小、治疗方式与预后有关(P值分别为0.046、0.007、0.007、0.009);多因素分析显示,仅治疗方式是独立的预后影响因素(P=0.013).11例宫颈微小偏离型腺癌患者中Ⅱb～Ⅲb期占7/11,而5例宫颈绒毛管状腺癌患者中Ⅱb～Ⅲb期仅1例.88例患者总体HPV感染率为65％(57/88),不同病理类型宫颈黏液腺癌的HPV感染率比较无明显差异.结论 宫颈细胞学检查对宫颈黏液腺癌的诊断意义不大;宫颈黏液腺癌早期容易漏诊,尤其是宫颈微小偏离型腺癌,宫颈组织大块切除活检、宫颈管搔刮术、诊断性锥切及宫腔镜检查有助于其诊断.治疗方式是影响宫颈黏液腺癌预后的重要因素.     

宫腔镜技术在计划生育中的临床应用

宫腔镜技术在计划生育中的临床应用发展迅速,已广泛应用于不孕症包括输卵管性不孕、宫颈及宫腔粘连性不孕,子宫畸形纠正,宫腔异物取出包括胎骨残留的取出、迷失和残存的宫内节育器的取出,子宫内膜息肉的诊断与治疗,子宫内膜骨化的诊断与治疗,绝育术等,还可应用于辅助生殖和异位妊娠的治疗。     

子宫内膜结核的宫腔镜检查和组织病理学诊断分析

目的:评价宫腔镜检查与组织病理学诊断子宫内膜结核的符合率与相关性。方法:回顾性分析2012年7月—2016年8月于首都医科大学附属复兴医院宫腔镜诊治中心就诊的有结核病史的99例不孕女性的病历资料,调取宫腔镜检查和子宫内膜病理结果,进行比较分析。结果:99例女性均行宫腔镜检查并同时行组织病理学检查,两者诊断符合率为46.7%,其中7例为宫腔镜检查与组织病理学检查一致检出子宫内膜结核,1例增殖期子宫内膜经宫腔镜识别存在结核但组织病理学检查未证实,8例组织病理学检查证实存在子宫内膜结核但宫腔镜下未检出;宫腔镜下检出不同程度宫腔粘连68例。结论:宫腔镜检查识别检出的子宫内膜结核必须经组织病理学证实方可诊断,宫腔镜检查有助于发现宫腔粘连。     

卵巢子宫内膜样癌及其合并子宫内膜异位症的临床及病理分析

目的探讨卵巢子宫内膜样癌及其合并子宫内膜异位症患者的临床、病理特征及预后。方法对中国医科大学第二临床学院和解放军202医院1990年1月至2004年12月40例卵巢子宫内膜样癌患者病理蜡块进行分析,16例为子宫内膜异位症恶变（EM组）,24例为原发卵巢子宫内膜样癌（NEM组）,同期50例原发卵巢浆液性囊腺癌为对照组。比较分析3组一般特征、临床表现、病理特点及预后。结果EM组较NEM组年轻9岁,较对照组年轻5岁,临床主要表现为盆腔包块及下腹胀痛,盆腔包块持续半年以上患者多见。NEM组主要为下腹胀痛及阴道不规则流血。EM组5年存活率为75.0%,NEM组为62.5%。结论子宫内膜异位症恶变患者发病年龄较轻,临床医生要认识子宫内膜异位症恶变为卵巢子宫内膜样癌的临床及病理特点,提高早期诊断率。     

子宫性不孕不育症患者行宫腔镜诊治的生殖预后分析

目的分析子宫性不孕不育症患者行宫腔镜诊治的生殖预后效果。方法回顾性分析我院2013年8月~2014年8月采用宫腔镜诊治的不孕不育症患者64例的临床资料,分析宫腔镜的诊断结果,同时找出患者不孕不育的异常因素。结果患者异常宫腔43例(67.19%),在异常宫腔中子宫内膜息肉与息肉样增生26例(60.46%),宫腔粘连11例(25.58%),继发不孕中,宫腔粘连为首,原发不孕中子宫内膜息肉与息肉样增生为首,习惯性流产中子宫纵隔为首。结论不孕不育症患者治疗前应采用宫腔镜做检查,有利于不孕不育症的诊疗,从而改善患者生殖预后。     

子宫恶性肿瘤诊治研究——子宫颈癌

子宫是孕育胚胎、胎儿和产生月经的器官。同时,子宫也是容易发生恶性肿瘤的器官。从子宫颈到子宫体,子宫内膜到子宫肌层,各部位均可发生恶性肿瘤。宫颈癌是最常见的妇科恶性肿瘤,高危型人乳头瘤病毒（HPV）的持续性感染是引起宫颈癌前病变和宫颈癌的主要原因。宫颈癌的主要病理类型为鳞状细胞癌和腺癌,确诊依赖于宫颈病灶的活体组织病理检查,对病变程度的判断采用国际妇产科联盟（FIGO）的临床分期。宫颈癌的治疗早期以手术为主,中、晚期以放疗为主,辅以化疗的综合治疗。近年来靶向治疗为局部晚期、复发性、转移性宫颈癌提供了新的治疗途径。HPV疫苗也已开始应用于宫颈癌的预防。     

Oestrogen Receptor Studies in Carcinoma of the Endometrium, Carcinoma of the Uterine Cervix and other Gynaecological Malignancies

The tissues from 30 cases of endometrial cancer and 44 cases of cervical cancer were examined for oestrogen receptor activity. Twenty of the endometrial and 9 of the cervical tumours contained oestrogen receptor levels above 4 fmol/mg protein. The proportion of oestrogen receptor-positive tumours was significantly greater in adenocarcinomas of the cervix than in squamous carcinomas of the cervix. Tissues from 3 mixed mesodermal tumours of the uterus, 2 carcinomas of the vagina, a carcinoma in situ of the cervix and a carcinoma in situ of the endometrium were receptor-negative. One ovarian carcinoma and a single case of uterine sarcoma were receptor-positive. The implications of these findings in relation to hormonal therapies are discussed.     

Primary in situ squamous cell carcinoma of the endometrium,with extensive squamous metaplasia and dysplasia

BACKGROUND: Primary squamous cell carcinoma of the endometrium is exceedingly rare. It has been described in association with pyometra but its etiology is still unclear. CASE: The authors report the case of a 75-year-old woman who presented with pelvic pain and pyometra. No gross tumor was identified in the uterus; however, extensive epidermalization of the endometrial mucosa was noted. Microscopic findings were consistent with a primary in situ squamous carcinoma of the endometrium associated with extensive squamous metaplasia and areas of dysplasia. HPV antigen and DNA detection were negative in both the endometrial lesions and the cervix. CONCLUSIONS: These results support the sequence of change with squamous metaplasia, progressing through dysplasia to carcinoma as a possible pathogenetic process. HPV's role, however, remains uncertain.     

Verrucous carcinoma of the endometrium: case history, pathologic findings, brief review of literature and discussion

BACKGROUND: Verrucous carcinoma is a rare condition. A defined disease of the oral cavity, larynx, esophagus, skin, vulva, vagina and cervix. But a verrucous carcinoma arising from the endometrium without evidence of cervical malignancy or endometrial adenocarcinoma is extremely rare. CASE: A 67-year-old G2P2 menopausal patient that was referred for consultation 1 year after presenting with vaginal bleeding to her gynecologist who subsequently underwent several endometrial biopsies where the pathological findings were repetitively similar: papillary squamous proliferation, cytologically bland with low mitotic activity but extensive proliferation. A hysterectomy with bilateral salpingo-oophorectomy was performed. The final histologic examination revealed a squamous cell carcinoma of endometrium, verrucous and well differentiated, and there was no cervical invasion identified. CONCLUSION: This is a rare form of endometrial cancer with apparent favorable prognosis that must be considered when squamous cells are identified on endometrial samplings.     

Intraepithelial epidermoid carcinoma of the cervix, endometrium, and a fallopian tube

A patient with intraepithelial epidermoid carcinoma of the uterine cervix, endometrium, and a fallopian tube is presented. This abnormality is discussed with particular attention to the association with chronic inflammation. This rare lesion might represent a superficial spread of atypical cervical epithelium to include the endometrium and fallopian tube or could reflect a field change. The effect of this finding upon the prognosis of intraepithelial carcinoma of the cervix is unknown.     

Primary squamous cell carcinoma of the endometrium. A report of 3 cases.

Primary squamous cell carcinoma of the endometrium (PSCCE) is a rare disease of unknown etiology. Diagnosis is based on the identification of squamous cell carcinoma in the endometrium with no coexisting analogous cervical component or endometrial adenocarcinoma. There must also be no connection between the endometrial tumour and the squamous epithelium of the cervix. Although the majority of patients are classified as stage I disease, prognosis is rather dismal. We report two new cases of primary squamous cell carcinoma of the endometrium which fulfill all the above criteria and we discuss another interesting case of squamous cell carcinoma of questionable endometrial origin. Management by abdominal hysterectomy and adjuvant pelvic irradiation resulted in long-term survival of our patients.     

An immunohistochemical study of the distribution of epithelial membrane antigen (EMA) in uterine carcinoma

Epithelial membrane antigen (EMA) is a component of the human milk fat globule membrane. The production of EMA is increased in both squamous and non-squamous epithelium in a variety of diseases including many neoplasms. Using antihuman EMA monoclonal antibody, an immunoperoxidase stain for EMA was done in normal or neoplastic cervical epithelia and endometrium. Formalin-fixed paraffin-embedded tissues were obtained by either colposcopic biopsy or surgical excision of the uterus from 61 patients. Ethanol fixed imprint smears were obtained from surgically removed uteri from 84 patients. The difference between normal cervical squamous epithelium and dysplasia or carcinoma of the cervix in intensity or patterns of staining for EMA reflected the progression of the neoplastic change in the cervix. The different EMA localization in well differentiated adenocarcinoma and moderately or poorly differentiated adenocarcinoma of the cervix and the endometrium was correlated with histological differentiation.     

血清鳞状上皮细胞癌抗原对子宫颈癌及CINⅢ的诊断价值

目的：探讨血清鳞状上皮细胞癌抗原（SCCAg）在宫颈癌诊断、疗效评估等方面的应用价值。方法：本研究选择了2011年9月—2012年3月天津市中心妇产科医院妇瘤科的住院患者145例,全部为可疑宫颈癌患者,经病理组织学确诊分为宫颈上皮内瘤变（CIN）Ⅲ组55例和宫颈癌组90例。采用化学发光的方法检测患者术前血清SCCAg的浓度,结合临床资料和病理组织学诊断,分析评价SCCAg与临床分期、组织分化程度的相关性及其对宫颈癌的诊断价值,通过术前与术后SCCAg检测值的比较评价其在疗效评估方面的价值。结果：血清SCCAg浓度在CIN组和宫颈癌组中的差异有统计学意义（P=0.000）,治疗后SCCAg水平较治疗前显著下降（P=0.000）;按国际妇产科联盟（FIGO）分期分组讨论,随疾病的进展,临床分期的加重,SCCAg的数值增高,阳性率亦增高,两者具有正相关性;SCCAg在可疑宫颈癌人群的检测敏感度为71.1%,特异度72.7%,准确度71.7%,阴性预测值60.6%,阳性预测值81.0%;CINⅢ的检测阳性率为27.3%,宫颈鳞癌Ⅰ期患者的检测阳性率为66.7%。结论：SCCAg对宫颈鳞状上皮细胞癌具有诊断价值,对疗效监测及预后判断也有重要临床意义,但在早期诊断方面仍有局限性,与宫颈癌的病理类型、临床分期有关,与组织分化程度无关。     

P~(16)蛋白在宫颈癌中的表达及其临床意义

目的：研究抑癌基因P16与宫颈癌发生、发展及患者预后的关系。方法：用免疫组化ABC法检测了10份正常宫颈组织、16份慢性宫颈炎及123份宫颈鳞癌组织中P16的表达情况。结果：P16在宫颈癌中检出率为43．90％，明显低于正常宫颈（80．00％）及宫颈炎组织（68．75％），P＜0．01。其中伴淋巴结转移的宫颈癌中P16蛋白表达率（22．22％）是显著低于无淋巴结转移者（61．11％），P＜0．05。P16蛋白表达阳性者5a存活率为52．63％，而阴性者仅为29．79％，P＜0．05。结论：P16蛋白的突变与缺失可能与宫颈癌的发生、发展密切相关。     

Squamous cell carcinoma of the endometrium. A case report.

Invasive squamous cell carcinoma of the endometrium occurred secondary to squamous cell carcinoma in situ of the cervix. There have been 27 previous reports of secondary endometrial squamous cell carcinoma and 31 of primary.